Editor's note: When we read Sharon Long and colleagues' retrospective on Massachusetts health reform at 10 years in the September issue of Health Affairs we were reminded just what a busy year 2006 was for health policy writ large (in addition to wondering 'Has it been that long already?'). Now a decade later, we think there's something to be gained from looking back on the impact and reach of some of the most significant policies implemented that year. With that in mind, Health Affairs Blog invited a handful of policymakers and researchers to reflect on some of these major milestones, share lessons learned, and discuss how our world has changed since then. Visit the Blog for more posts in this occasional series.
Almost 10 years have passed since the New York City (NYC) Board of Health took an unprecedented step and amended the City Health Code to restrict the use of trans fat in NYC restaurants. This move would be followed by similar actions across the country, contributing to mounting evidence that trans fat could, and should, be eliminated from our food supply. Then, in 2015, the Federal Food and Drug Administration (FDA) took a definitive regulatory action that will help protect the heart health of all Americans by removing virtually all artificial trans fat from our food.
The trans fat story started in the early 20th century when industrial food manufacturers found a new advantage in the partial hydrogenation of unsaturated vegetable oils and fats (PHVOs). This industrial process creates the fatty acids that make liquid oils solid, increases product shelf life, and produces fry oils with greater stability at high temperatures. Pie crusts made with Crisco, grocery store shelves stocked with Wonder bread, and restaurant french fries are examples of products that once commonly contained PHVOs. In the 1970s, PHVO use was promoted as a healthier alternative to saturated fat; think margarine in place of butter. By the late 1990s, PHVO was the source of almost 80 percent of all trans fat in the US diet with only about 20 percent of trans fat coming from naturally occurring sources like some meats and dairy products.
In 1958, Congress passed the Food Additives Amendment, assigning the most commonly used PHVOs "generally recognized as safe" (GRAS) status based on their common use in food. If a substance has GRAS status, that substance is not considered a food additive, and industry can use it without having to show the FDA that it's safe. In the early 1990s, however, scientific studies began to reveal concerning findings. In 2002, the National Academy of Science's Institute of Medicine reviewed existing evidence and found a linear increase in coronary heart disease with increasing trans fat intake, suggesting a "Tolerable Upper Intake Level of zero." The IOM went on to conclude that, because trans fatty acids are unavoidable in ordinary diets, eliminating them entirely "would require significant changes in patterns of dietary intake" that could keep many Americans from getting adequate protein and certain micronutrients, potentially introducing "undesirable effects…and unknown unquantifiable health risks."
A Call to Action
The NYC Department of Health and Mental Hygiene (DOHMH) exists to protect and promote the health of all New Yorkers. In 2006, I was directing the City's cardiovascular disease prevention and control program when we looked at the IOM's scientific declaration that trans fat was unsafe but virtually unavoidable in the food supply. My colleagues and I at DOHMH found such a statement unacceptable, especially because most trans fat was added to the food supply, not naturally occurring. Certainly government, including through the regulatory framework that is designed to assure the safety of our food supply, should be compelled to act. In New York City, we did.
We first used the government's weight to recommend that restaurants restrict their use of trans fat. When our voluntary approach proved ineffective, we moved to regulate trans fat, restricting its use in restaurants. Evaluation showed that it worked. The percentage of restaurants using oils containing trans fat for frying, baking, cooking, or in spreads dropped from 50 percent before the regulation to 1.6 percent after it took effect. In chain restaurants, the average trans fat content of noon-time purchases was shown to decrease by 2.4 grams to 0.5 grams.
A unique position
New York City's action on trans fat was made possible by the decades of academic research and consumer advocacy that preceded our planning, and we built upon the work of others who had tested approaches to remediation. We were not the first to use regulation to restrict trans fat use—the Danish government did it in 2003—but we were the first local government to regulate its use in restaurants in the United States. Since then, more than 15 others have followed suit, including the cities of Philadelphia and Seattle and the State of California.
Our work on trans fat, as well as on a number of other recent nutrition policies, such as restaurant calorie labeling and the National Salt Reduction Initiative, is germane to the work of every local health department across the country. While our primary charge is to improve the health of the community we serve, health departments also have the ability to make unique and game-changing contributions to the health of the nation at large. This is by design.
The Tenth Amendment of the US Constitution reserves for the states all powers not prohibited by or already delegated to the federal government, including the authority and responsibility to pass laws to protect the health and safety of their residents. As such, local and state government can create and test policies, according to their elected government and regulatory framework. Compared with the federal government, local and state governments are relatively nimble, able to design, implement, and evaluate new interventions in a relatively short period of time. In every community, local agencies have a diverse array of opportunities to take on some of our most vexing public health challenges, should they so choose. And from them, we all learn.
Evaluating and publishing what doesn't work—like our voluntary approach to trans fat removal in restaurants—is just as important as sharing what does. Lessons learned and disseminated can inform best practices, and signal to Federal agencies public support for related action at the national level. The FDA's decision to remove trans fat from GRAS status, to propose Federal guidance on sodium levels in our food supply, and to adopt restaurant calorie labeling through the Affordable Care Act are all examples of national nutrition policy around which NYC had been a leader and innovator at the local level.
I've now worked in local or federal government for over 10 years with a focus on chronic disease prevention and control. The public health problems we face are real and daunting and unacceptable health inequities persist across our country. According to the Center for Disease Control and Prevention's 2014 BRFSS Prevalence & Trends Data, almost two thirds of Americans are overweight or obese. And according to our analysis of New York City's 2014 Vital Statistics, black residents die early from heart disease at rates 1.8 times higher than whites, a pattern not unique to our city.
The solutions don't have to be regulatory or legislative or even led by government, but they do need to be big, meaningful, and enduring if they are going to make a difference in protecting health for all. Governments, local and state, are vehicles to support rapid innovation, evaluation, and the dissemination of best practices so that the learnings of any of our communities may benefit all of our communities.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2eDnYjy
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